51 results
60y · Female·acute cerebral bleed resulting from blunt trauma and late haemorrhagic progressi…
Gwenith Elkington, aged 60, died from acute cerebral bleed resulting from haemorrhagic progression of a traumatic brain injury sustained in a bathroom fall on 21 September 2015. The injury caused a contre coup contusion …
47y · Female·complications of rapidly progressing motor neurone disease
A 47-year-old woman with motor neurone disease died from respiratory complications while in immigration detention, residing in aged care. She collapsed at 1:00am with respiratory distress. Nursing staff did not attempt C…
17y · Male·Cardiac arrhythmia during restraint, with previous traumatic brain injury as a s…
Pono Aperahama, a 17-year-old with severe traumatic brain injury and moderate intellectual disability, died from cardiac arrhythmia during restraint at a swimming pool. His escalating behaviour in 2017—triggered by schoo…
22y · Male·hypoxic ischaemic encephalopathy as a result of hanging
Tane Chatfield, a 22-year-old Aboriginal man, died by hanging in his prison cell at Tamworth Correctional Centre on 20 September 2017. He had been admitted to hospital the preceding night with seizures, assessed as unlik…
3y · Male·respiratory failure, with spinal muscular atrophy an antecedent cause
Tory Ganderton, a 3-year-old boy with spinal muscular atrophy (SMA) Type 1, died of respiratory failure during inter-hospital transfer. Admitted to Shoalhaven Hospital on 7 September 2014 with pneumonia and severe malnut…
35y · Male·subarachnoid haemorrhage with antecedent ruptured cerebral artery aneurysm
Eric Whittaker, a 35-year-old Aboriginal man, died from a subarachnoid haemorrhage caused by a ruptured cerebral artery aneurysm while in remand custody at Parklea Correctional Centre. On 2 July 2017, he made 20 emergenc…
5y · Male·Combined effects of prescribed morphine, valproic acid and midazolam leading to …
A five-year-old child with complex neurodevelopmental conditions and polypharmacy (including valproic acid for epilepsy, benzodiazepines, and other medications) underwent routine burn dressing change at hospital with ora…
35y · Female·hypoxic brain injury, with strangulation being an antecedent cause
Blair Dalton died from hypoxic brain injury following strangulation by her partner LP on 26 September 2017. She was resuscitated at the scene and admitted to Gosford Hospital ICU but suffered irreversible brain injury. L…
Unknown·Alan Bugden: pulmonary thromboembolism after stroke. Amaru Bestrin: combined dru…
Two deaths occurred in hospital toilets due to undetected collapse in publicly accessible facilities. Alan Bugden, 66, suffered a stroke in an ambulatory care centre toilet at Royal North Shore Hospital and remained unde…
20y · Male·massive basal subarachnoid haemorrhage caused by a blow to the head
A 20-year-old man died in 1971 from a subarachnoid haemorrhage that was initially attributed to spontaneous rupture of a cerebral artery aneurysm. An inquest 45 years later, based on neuropathological expert evidence, fo…
46y · Female·hypoxic ischaemic brain injury as a result of cardiac arrest following a choking…
Andrea Sewell, a 46-year-old woman with Osmotic Demyelination Syndrome (ODS) and acute psychiatric illness, died from hypoxic brain injury following a choking episode during a meal in a psychiatric intensive care unit (P…
49y · Male·Complications of metastatic gastric adenocarcinoma
Ahmed Rizk, a 49-year-old man in custody, died from complications of metastatic gastric adenocarcinoma. He presented with abdominal pain and constipation on 10 August 2017, was investigated at Glen Inness District Hospit…
0y · Male·neonatal encephalopathy due to perinatal compromise
Jaxon McGrorey-Smith, a full-term neonate, was delivered by caesarean section after prolonged labour. He developed seizures and signs of hypoxic-ischaemic encephalopathy (HIE) within hours of birth, with MRI imaging conf…
82y · Male·Acute kidney failure due to possible sepsis or cardiogenic shock, with congestiv…
Ian Turnbull, a 82-year-old man in custody, died from acute kidney failure due to possible sepsis or cardiogenic shock with congestive cardiac failure. He had multiple comorbidities including ischaemic heart disease, hyp…
5y · Male·complications of blunt force injury to the head
A 5-year-old boy died from complications of blunt force head injury sustained on 19-20 March 2010. He presented to a rural hospital unresponsive, with the initial account not mentioning head trauma. The attending doctor …
28y · Female·complications of epilepsy
Carney Schultz, a 28-year-old woman with severe cerebral palsy, hydrocephalus, and epilepsy, died on 21 April 2015 at a group home. She experienced a seizure around 3:20am managed by a disability support worker (DSW) wit…
82y · Male·complications of metastatic pancreatic cancer with end stage liver failure
An 82-year-old man died of end-stage liver failure due to metastatic pancreatic cancer while serving a custodial sentence. He was comprehensively assessed on entry to prison and housed in an Aged Care Unit where his mult…
62y · Male·undetermined
Thangarajah Sithamparapillai, a 62-year-old accountant, disappeared on 9 October 2015 after being last seen in bed appearing unwell. His car was found at Coogee beach car park. The coroner found he died on or about 9 Oct…
46y · Female·Prolonged effects and complications of a head injury, with upper airway obstruct…
Helen Ashburn, a 46-year-old woman with history of alcohol use, coagulopathy and seizures, died from prolonged effects of a severe head injury sustained on 25 October 2011. She presented to Kempsey Hospital with extensiv…
29y · Male·Unascertained
AR was a 29-year-old man with autism, developmental disability and epilepsy living in a residential disability care facility. He was found unconscious and died suddenly on 30 August 2010. Initial post-mortem findings sug…
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